Click to highlight the findings that indicate an improvement in the client’s condition. To deselect a finding, click on the finding again. Exhibits Nurses' Notes Day 4, 0905: Child is resting comfortably in bed. Alert and oriented to time, place, and person. Caregivers report child has been interactive and showing increased interest in eating. Child engages with staff and caregivers appropriately for age. No headache and no pain reported during neck flexion. Brudzinski and Kernig signs are negative. Mucous membranes are moist. Skin is warm, without cyanosis and capillary refill is less than 2 seconds. Pupils are equal round and reactive to light accommodation, with no squint observed in room lighting Lungs clear to auscultation. S, and S2 heard without murmurs. Abdomen is soft and nontender, with hypoactive bowel sounds in all quadrants. Vital Signs Day 4, 0905: Temperature 37° C (98.6° F) Heart rate 90/min Respiratory rate 22/min Blood pressure 105/68 mm Hg Oxygen saturation 98% on room air Weight 20 kg (44 lb)
Explanation & Rationale
Rationale for Correct Choices: Neurologic improvement is evident as the child is now alert, oriented, interactive, and no longer experiencing headache or positive Brudzinski/Kernig signs. This indicates resolution of meningeal inflammation. Hydration and circulation have improved; moist mucous membranes, warm skin, no cyanosis, and capillary refill under 2 seconds show good perfusion and fluid balance. Photophobia resolution is seen in the child’s normal pupil response without squinting in room light, suggesting reduced intracranial irritation. Vital signs normalization including a temperature of 37° C that has improved from 39 degrees indicating an improvement in the condition and resolution of infection. Rationale for Incorrect Choice: Hypoactive bowel sounds are not a sign of improvement and may indicate slowed gastrointestinal motility or residual effects of illness or immobility.